Pre-Construction Risk Assessment

Infection Control / Safety Construction Permit

Location of Construction:
Project Coordinator:
Contractor Performing Work:
Supervisor:

Project Start Date:

Estimated Duration:
Permit Expiration Date:
Telephone:

Description of project:

Construction Activities
The following projects do not require completion of the Pre-construction risk assessment form:
1. Paint and wallpaper in business offices and non-patient areas.
2. Paint in patient room if closed for painting and less than 3 sq.ft. of wall needs patched. Filter for room unit changed after painting.
3. Installation of soap dispenser/needle box/paper towel holder in patient room
4. Repair of window blind.
5. Ceiling tile replacement for areas less than 10 2 X 2 tiles, if not in business offices and non-patient areas.
6. Ceiling tile replacement for area less than 5 2 X 2 tiles in a patient area if patient is out of the immediate area and clean up can be
Accomplished before patient returns.
7. Minimum repair of nurse call system/TV/Bed/Telephone.
8. Check or replace electric outlet.
9. Replace light bulb.
10. Unstop sink/commode with no water on floor.
11. Unstop commode when water on floor requires maintenance to have Housekeeping clean area immediately.
12. Repair medical gas outlet. (Front Body)
13. Air balance readings.
14. Check air-conditioning.
15. Intermediate jobs that create a moderate amount of dust inside room and is made negative by use of hepa-equipped unit with minimum 10
ACH, and all air discharged outside, hepa unit must run 2 hours after completion of job and Housekeeping must clean room before unit is
removed from room. All work and use of hepa unit must be documented and copy forward to Infection Control and Safety. NOTE: all duct
vents to be sealed off during work!
Yes
No
Will there be noise generated that will impact a department adjacent to, above, or below the construction area?
a. If so, these departments must be notified.
b. How are you going to reduce the noise to an acceptable level?

Yes

No
Will there be vibration generated that will impact a department adjacent to, above, or below the construction area?
a. If so, these departments must be notified each time this type of work will be performed.
b. How are you going to reduce the vibration to an acceptable level?

Yes

Yes

Yes

No

No

No

Are Emergency Procedures in place and posted on each job for accidental events that could greatly impact Patient Care or Life
Safety to the facility? Included in these procedures are such things as:

Emergency telephone numbers of key departments.

A plan that describes where main valves, switches, and controls are for the area in case of an emergency.

A plan for unexpected outages.

Environment
Are any of the following environmental hazards present?
Will hazardous chemicals be used on this project? How will fumes and odors be controlled? MSDS Sheets are required.

Is asbestos abatement required on this job? If so, notify Safety and Maintenance at the activation.
Will there be hot work done on this project? If there are, then a hot work permit must be posted on the job site. All hot work must have a
fire watch assigned to each area while the hot work is being performed.
Will there be a Confined Space Entry required on this project? If so, the CAMC confined space entry program must be followed.
Utility Failures
Will any of the following systems be out of service at any time during the project?

Fire alarm (If out for more than 4 hours, Interim Life Safety Measures must be implemented.)
Sprinkler (If out for more than 4 hours, Interim Life Safety Measures must be implemented.)
Electrical
Domestic water
Oxygen
Sewage
HVAC

Yes

No
Will there be any work that will require activation of the Interim Life Safety Measures during this project? Some things that will
ILSMs to be implemented are but not limited to:

Any construction that impacts an EXIT or stairs,

Any construction that impacts major breaches in a fire or smoke wall,

Taking the main fire protection system out of service (sprinkler),

Taking the main fire alarm system out of service,

Taking the area fire or fire alarm systems out of service for more than 4 hours within a 24-hour period.
Implementation of the ILSM requires a fire watch and the ILSM forms to be completed.

Additional Safety Concerns

Yes
No
Will construction affect exit routes from occupied areas adjacent to construction site?
Will project affect traffic patterns in area? If yes, explain plan.

The following must be completed prior to any construction activities.

Separation wall must be constructed prior to project beginning.

Fire protection systems must remain intact.

Provide extra fire extinguishers in work areas.

Maintain exit lights in work area.

Maintain negative air in construction area (24/7) through duration of project.

There cannot be any return air from within the construction area to the rest of the building.

Redirect exiting not to go through construction area.

Put signs on doors into construction area Construction Area Do Not Enter.

Maintain daily logs and keep a current Hot Work Permit.

Place sticky mats at doors exiting construction area.

All debris removal must be by covered cart.

Maintain clean and orderly work area.

How will this project affect the departments above, below and adjacent to this project?

Air Quality and Infection Control

The construction activity types are defined by the amount of dust that is generated, the duration of the activity, and the amount of shared HVAC
systems. Contact CAMC s Safety Department and Clinical Epidemiology Department if any activity is questionable under these guidelines.
Yes
No
Will dust be generated during this project?
If yes, explain location of and plan for interim dust barriers or attach floor plan with barriers clearly marked.

Will debris removal be necessary? If yes, explain plan for debris removal and control.

Negative airflow ventilation and filtration in place and assessed for effectiveness.
Exhaust fans in place and functioning.
Is supply duct to area closed and HEPA filtration unit in place and functioning in adjacent patient care area?
Will work be done in a sterile area? If so, how are you going to maintain sterile atmosphere in work area and access to and from
work area?

Type A
Yes
No

Inspections and Non-Invasive Activities or Small scale, Short duration Activities

Removal of ceiling tiles for visual inspection (limited to 1 tile per 50 square feet)
Painting (but not sanding)
Wall coveringDescribe work to be done:

Type B
Yes
No

Electrical trim work. Describe:

Minor plumbing. Describe:
Small scale, short duration activities that create minimal dust.
Installation of telephone and computer cabling
Access to chase spaces
Sanding of walls for painting or wall covering (minor repairsnot sanding for drywall finishing)

Type C
Yes

Any work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components
or assemblies. (May require approval from State Fire Marshal and Health Department prior to beginning project)
No
Sanding of walls--drywall finishing
Removal of floor coverings
ceiling tiles
casework
Describe:
Cutting of walls or ceiling. Describe:
New wall construction
Minor ductwork or electrical work above ceilings
Major cabling activities
Activity cannot be completed within a single work shift
Has approval been obtained from State Fire Marshal and Health Department?
Major demolition and construction projects. (State Fire Marshal and Health Department approval required)

Type D
Yes
No

Will require heavy demolition or removal of a complete ceiling system

New construction
Has approval been obtained from State Fire Marshal and Health Department?
GROUP I
LOWEST
1.) Office areas

GROUP 2
MEDIUM
1) All Med/Surg units
2) Physical Therapy
3) Sports Medicine
4) Admission/Discharge area
5) Outpatient areas

GROUP 3
GROUP 4
HIGH
HIGHEST
1) Operating Rooms; Sterile Processing
1) Emergency Room
2) Labor and Delivery Operating Rooms
2) Radiology/MRI
3) Cardiac & EP Catheterization & Angiography Areas
3) Post-anesthesia Care units
4) Oncology
4) Labor and Delivery
5) Dialysis/Home Training
5) Newborn Nurseries
6) Renal Services Unit
6) Pediatrics
7) Renal Transplant
7) All other Intensive Care Units
8) Cardiology
8) Nuclear Medicine
9) Anesthesia and Pump areas
9) PT tank areas
10) Endoscopy/Minor Surgery
10) Cafeteria
11) Pharmacy Admixture
11) Echocardiography
12) Surgicare
12) Laboratories
13) Central Services
13) Occupational Lung Center
Contact the Clinical Epidemiology Department for risk assessment of any area not listed above.

CONSTRUCTION ACTIVITY (from previous page)

INFECTION CONTROL RISK GROUP (see above)

Check type of activity

Check risk group

TYPE A: Inspection, non-invasive activity

GROUP 1: Lowest Risk

TYPE B: Small scale, short duration projects

GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of

dust, requiring >1 work shift for completion

GROUP 3: High Risk

TYPE D: Major duration and construction activities

Requiring consecutive work shifts

GROUP 4: Highest Risk

CLASSIFICATION OF REQUIRED PREVENTIVE MEASURES

CONSTRUCTION ACTIVITY
TYPE
TYPE
TYPE
INFECTION CONTROL
A
B
C
RISK GROUP
I
I
II
Group I

TYPE
D
III/IV

Group 2
Group 3
Group 4

I
II
III

I
III

III
III/IV

IV
IV

III/IV

III/IV

IV

An Infection ControlSafety Construction Permit is required for Class III or higher projects. Refer to shaded area on
Construction Activity/Risk Group Matrix (above).
CLASS I

1.

Execute work by methods to minimize raising dust from

construction operations.

2.

Immediately replace any ceiling tile displaced for visual

inspection.

CLASS II

1.

Provide active means to prevent air-borne dust from

dispersing into atmosphere
Water mist work surfaces to control dust while cutting.
Seal unused doors with duct tape.
Block off and seal air vents.
Wipe surfaces with disinfectant.

6.

Contain construction waste before and during transport in tightly

covered containers.
Wet mop and/or vacuum with HEPA filtered vacuum before
leaving work area.
Place dust mat at entrance and exit of work area as needed.
Remove or isolate HVAC system in areas where work is being
performed.

2.
3.
4.
5.

7.
8.
9.

CLASS III

1.
2.
3.
4.
5.
6.

Class IV

1.
2.
3.
4.
5.
6.

Obtain infection control permit before construction begins.

Isolate HVAC system in area where work is being done to
prevent contamination of the duct system.
Complete all critical barriers before construction begins.
Maintain negative air pressure within work site utilizing
HEPA equipped air filtration units.
Contain construction waste before and during transport in
tightly covered containers.
Seal holes, pipes, conduits, etc. appropriately.
Obtain infection control permit before construction begins.
Isolate HVAC system in area where work is being done to
prevent contamination of duct system.
Complete all critical barriers or implement control cube
method before construction begins.
Maintain negative air pressure within work site utilizing
HEPA equipped air filtration units.
Seal holes, pipes, conduits, and punctures appropriately.
Construct anteroom and require all personnel to pass
through this room so they can be vacuumed using a HEPA
vacuum cleaner before leaving work site or they can wear
cloth or paper coveralls that are removed each time they
leave the work site.

7.
8.

Place dust mat at entrance and exit of work area. Replace as

needed.
Do not remove barriers from work area until completed project is
inspected by Safety and Epidemiology Depts. and thoroughly
cleaned.

After work is completed:

9. Remove barrier materials carefully to minimize spreading of dirt
and debris associated with construction.
10. Remove isolation of HVAC system.
7. All personnel entering work site are required to wear shoe
covers
8. Contain construction waste before and during transport in tightly
covered containers.Cover transport receptacles or carts. Tape
covering.
9. Do not remove barriers from work area until completed project is
inspected by Safety and Epidemiology Depts. and thoroughly
cleaned.
After work is completed:
10. Vacuum work area with HEPA filtered vacuums.
11. Wet mop with disinfectant.
12. Remove barrier materials carefully to minimize spreading of dirt
and debris associated with construction.
13. Remove isolation of HVAC system.

Additional concerns for all classes:

1. Maintain manpower and equipment including dust mops, wet mops, brooms, buckets, and clean wiping rags for
cleaning fine dust from floors and adjacent occupied areas.
2. Contain work areas outside of construction barriers, including spaces above ceilings, with full height polyethylene
sheet barrier, tightly taped.
3. Clean up dust tracked outside of construction area immediately.
4. Temporary construction barriers and closures above ceiling must be dust tight.
5. Removal of debris must be in covered containers.
Additional Requirements or Concerns:

Permit Request By

Date:

Safety Approval

Date:

Clinical Epidemiology Approval

Date: